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PubMed2001

Reoperation for hyperparathyroidism in multiple endocrine neoplasia type 1.

BACKGROUND: Patients with multiple endocrine neoplasia type 1 and hyperparathyroidism often undergo multiple operations because of inadequate initial surgery, presence of supernumerary and ectopic glands, regrowth of remnant glands, or autograft hyperfunction. Management of this patient population is complex. METHODS: From January 1975 to December 2000 we performed 94 reoperative parathyroidectomies consisting of 79 neck reexplorations, 12 autograft removals, and 3 median sternotomies in 75 patients. Data were gathered by retrospective chart review and follow-up telephone interviews. RESULTS: Excluding autograft excision, reoperative surgery was successful (normocalcemia longer than 6 months) in 91%; autograft removal was successful in only 58%. With a median follow-up of 59 months, 64% of patients are currently free from hypercalcemia, and this outcome was not influenced by the total number of glands resected. The median time to recurrent hypercalcemia was 125 months. Thirty patients received an autograft after reoperation. The complication rate for all reoperations was 12%, including permanent recurrent laryngeal nerve injury in 2 patients (2.1%). CONCLUSIONS: Reoperative parathyroidectomy in patients with multiple endocrine neoplasia type 1 was safe and successful in the majority of patients; however, recurrent hyperparathyroidism is likely to develop in most individuals beyond 10 years of follow-up. The total number of glands accounted for after reoperation is not associated with successful outcome.

Adult↗

PubMed1987

Hemorrhagic complications resulting in reoperation after peripheral vascular surgery: a fourteen-year experience.

Eighty-nine patients who underwent reoperation because of hemorrhagic complications after peripheral arterial surgery were studied and compared with 103 patients without such complications. Elevation of erythrocyte sedimentation rate, serum creatinine values, and blood pressure before anesthesia was found more often in patients with hemorrhage. The frequency of reoperation due to control hemorrhage was 2.8%; femorodistal and carotid reconstructions were complicated by hemorrhage requiring reoperation significantly more often than other types of vascular surgery, 3.2% and 4.2%, respectively. The use of vacuum drains apparently did not contribute to the diagnosis of bleeding requiring reoperation. Amputation was a more frequent outcome in femorodistal reconstructions complicated by hemorrhage than in similar operations without this complication. After reoperations performed within 48 hours of the primary operation, the clinical course mostly was uncomplicated, whereas in reoperations performed later the bleeding usually was associated with infection of the reconstruction, resulting in a higher frequency of amputation. Most of the late hemorrhages occurred in groin incisions.

Amputation, Surgical↗

PubMed1994

Reoperative pancreaticoduodenectomy.

OBJECTIVE: The preoperative diagnostic strategy and operative technique for reoperative pancreaticoduodenectomy were outlined and operative mortality, perioperative morbidity, and early survival data in carefully selected patients undergoing reoperation for pancreatic cancer were analyzed. SUMMARY BACKGROUND DATA: Many patients with localized, nonmetastatic cancer of the pancreas undergo exploratory surgery with limited preoperative assessment of resectability. Frequently, pancreaticoduodenectomy is not performed because cytologic or histologic proof of diagnosis is lacking, or tumor resectability is questioned. Many patients are denied reoperation and a potentially curative resection because of the unacceptable morbidity and mortality believed to accompany pancreaticoduodenectomy in the reoperative setting. METHODS: Twenty-three patients who had undergone previous surgery for palliation or diagnosis of a pancreatic head mass were reoperated on after a standardized preoperative imaging evaluation consisting of chest radiography, computed tomography, and visceral angiography. A standardized operative technique was used on all patients, but was modified based on altered anatomy from the initial operation. RESULTS: Based on preoperative imaging studies, 19 of the 23 patients believed to have resectable tumors underwent laparotomy for planned pancreaticoduodenectomy; resection was accomplished in 14 patients. Seven of the fourteen patients required extended resections that included the superior mesenteric vein, right colon, or both. There was no perioperative mortality, and early complications occurred in 3 of the 14 resected patients. Four patients underwent planned palliative procedures. Four of ten patients who underwent resection for adenocarcinoma are without evidence of disease at a median follow-up of 26 months. CONCLUSIONS: Reoperative pancreaticoduodenectomy can be performed safely and may result in prolonged survival in carefully selected patients with resectable, localized pancreatic cancer.

Combined Modality Therapy↗

PubMed1997

A longitudinal, statistical study of reoperation rates in craniosynostosis.

A prospective, statistical study of reoperation rates was done in the treatment of 167 consecutive children with nonsyndromic and syndromic craniosynostosis over a 6-year period at Scottish Rite Children's Medical Center in Atlanta, Georgia. Mean length of follow-up was 2.8 years, with a range of 3 months to 6 years. Reoperation equal to or exceeding the magnitude of the original procedure occurred in 7 percent of cases. Multiple regression analysis revealed several factors associated with reoperation: Females and children with syndromic synostoses were more likely to require reoperation. Total reoperation rates for syndromic and nonsyndromic synostoses were 27.3 and 5.9 percent, respectively. Age at initial surgery, length of operation, and estimated blood loss did not predict a higher reoperation rate.

Child↗

PubMed1994

Characteristics in Medicare beneficiaries associated with reoperation after lumbar spine surgery.

STUDY DESIGN: A cohort study was undertaken using medical claims of Medicare beneficiaries. OBJECTIVES: Factors associated with reoperation after lumbar spine surgery were identified. SUMMARY OF BACKGROUND DATA: Repeat spine surgery is one outcome measure of surgical success, but little is known about clinical or demographic factors associated with repeat surgery. METHODS: Medicare beneficiaries who had surgery in 1985 were included in follow-up through 1989. Time between the first operation and a lumbar spine reoperation, death, or end of follow-up period was recorded. Survival analysis (time-to-event) techniques were used to test the association of baseline characteristics with reoperation. RESULTS: Higher reoperation rates were associated (P < 0.05) with previous back surgery, younger age, recent hospitalization, white race, and diagnosis of herniated disc (compared with other diagnoses). Fusion alone or combined with other procedures did not lower the reoperation rate. CONCLUSION: Reoperation rates are affected not only by technical factors, but also by demographic and clinical characteristics that are often omitted from reports of surgical case series.

Age Factors↗

PubMed2006

Achieving a zero percent reoperation rate at 3 years in a 50-consecutive-case augmentation mammaplasty premarket approval study.

BACKGROUND: Excessively high reoperation rates in breast augmentation premarket approval studies are a major concern of patients and the U.S. Food and Drug Administration. Over the past two decades, reoperation rates have remained between 13 and 20 percent at 3 years in three different premarket approval studies for three different types of implant devices, indicating that high reoperation rates are not device dependent. The hypothesis of this study was that implementing specific peer-reviewed and published processes can significantly reduce reoperation rates in a premarket approval study. METHODS: Fifty consecutive primary breast augmentation patients were enrolled in a premarket approval study for the Inamed Style 410 form stable, cohesive gel implant. All patients were treated specifically according to the premarket approval protocol. The series was monitored throughout the study by an independent clinical review organization and by a U.S. Food and Drug Administration inspection of the patient records on site at the author's practice. Specific content and processes were applied to patient management in patient education and informed consent, patient and surgeon decision-making processes, preoperative assessment and operative planning, implant selection based on individual patient tissue characteristics, surgical techniques, and postoperative care techniques. RESULTS: Follow-up was 100 percent (50 of 50 patients) at 1 year, 98 percent (49 of 50 patients) at 2 years (one patient could not be reached), and 94 percent (47 of 50 patients) at 3 years. No reoperations were performed on any patient followed at 3 years in the 50-consecutive-patient series. CONCLUSION: Implementing the peer-reviewed and published processes described in this study, no reoperations were performed in a prospective 50-consecutive-case series of primary augmentation mammaplasty patients in a premarket approval study with 94 percent follow-up at 3 years.

Adult↗

PubMed2005

Reoperative pancreaticoduodenectomy for periampullary carcinoma.

BACKGROUND: Potentially resectable periampullary tumours may not be treated appropriately due to lack of local expertise in both assessment of resectability and resection in referring centres. Tata Memorial Hospital is a major referral centre for oncology and these patients are finally referred to this institution. In carefully selected patients, resection can be accomplished. The purpose of the present paper was to determine the perioperative morbidity and mortality for patients undergoing reoperative pancreaticoduodenectomy at a major comprehensive cancer centre. METHODS: Between January 1991 and December 2001 15 patients, who had undergone previous non-resectional surgery for operable periampullary carcinoma, underwent re-exploration. The perioperative morbidity and mortality were analysed and compared with that of the group of patients undergoing primary pancreaticoduodenectomy (143 patients) in the same period. RESULTS: All the 15 patients undergoing re-exploration had a successful resection by pancreaticoduodenectomy. In the reoperative group eight patients (53%) underwent classic pancreaticoduodenectomy and seven patients (46%) had a pylorus-preserving pancreaticoduodenectomy, as compared to 102 (71%) and 41 (29%) patients in the primary surgery group, respectively. Although the mean operative time and the estimated blood loss were higher in the reoperative group, the morbidity and mortality rates were similar in the two groups. The overall 30-day mortality rate was 6.6% and 6.9% in the reoperative and the primary surgery group, respectively. Major morbidity occurred in two of the 15 patients (13.3%), and one patient (6.6%) died following surgery in the reoperative group. CONCLUSION: Reoperative pancreaticoduodenectomy can be performed safely in carefully selected patients with resectable, localized periampullary tumours with similar morbidity and mortality to patients undergoing primary surgery.

Adenocarcinoma↗

PubMed1998

Retreatment of children after surgery for acquired esotropia: reoperation versus botulinum injection.

AIMS: Two viable options were compared, reoperation and botulinum toxin injection, in the management of children who need retreatment after surgery for acquired esotropia. METHODS: 47 strabismic children previously operated to correct an acquired esotropia were randomised to reoperation or botulinum toxin injection. Reoperation was undertaken in 24 of these patients and botulinum toxin injection in 23 of them. The percentage net change in distance deviation, the percentage of patients with successful motor outcome, detectable fusion, and stereopsis were compared 1 year after retreatment and at last visit (average follow up: 2.9 years in reoperation group, and 2.7 years in botulinum group). The motor success rate relative to time elapsed from initial surgery was evaluated. RESULTS: There was no significant difference in the motor and sensory outcomes between patients reoperated and treated with botulinum injection. The frequency of correction to within 8 prism dioptres of orthotropia was, respectively: 75% versus 69.56% at 1 year; 70.83% versus 60.86% at last visit. Botulinum injection could be more effective when performed within 3 months of initial surgery. CONCLUSIONS: Botulinum injection is a rapid and safe procedure that may be as effective as reoperation in the management of children who need a secondary procedure after surgery for acquired esotropia.

Botulinum Toxins↗

PubMed1997

Results and complications after reoperation for failed epilepsy surgery in children.

The seizure outcome and neurological outcome in children who undergo reoperation for failed epilepsy surgery have not been well documented. This retrospective study evaluated 20 children who underwent a second resective surgery for recurrent seizures. Four categories of patients were identified: (1) extension of the initial resection was performed in 8 patients; (2) 5 patients underwent lobectomy or corticectomy in a region remote from the original surgical site; (3) multilobar resection which may have included further resection of the initial procedure was accomplished in 4 patients; (4) hemispherectomy was performed in 3 patients. Patients with reoperation in the same lobe as the first procedure (group 1) had a 62% seizure-free rate, while 44% of patients in groups 2 and 3 were free from seizures at follow-up evaluation. Patients undergoing hemispherectomy had a 67% seizure-free rate. Significant unexpected neurological deficits occurred in 3 patients who underwent multilobar resection at reoperation. Complications included motor and language deficits. Reoperation for intractable partial epilepsy is beneficial in selected children. Patients who require multilobar resections may have higher risk of postoperative neurological deficit than those patients with reoperation in one lobe. These factors may be useful in counseling parents of children considering reoperation for recurrent epilepsy.

Adolescent↗

PubMed1985

The rationale for planned reoperation after unplanned total excision of soft-tissue sarcomas.

Multimodality management of soft-tissue sarcomas of the extremity is often based on the presence or absence of residual primary disease. Reoperation is warranted or radiotherapy doses altered if the physician is aware that the tumor was incompletely excised. Most patients with soft-tissue masses undergo an initial excision before definitive therapy. These initial unplanned total excisions are usually excisional biopsies for presumably benign disease. Ninety patients were reviewed to evaluate the adequacy of unplanned total excision. All patients underwent unplanned supposed total excisions. Most patients were then treated with preoperative intraarterial Adriamycin (Adria Laboratories, Columbus, Ohio) and radiation therapy, followed by wide reexcision of the prior operative field. Forty-six patients (51.1%) had no gross residual tumor in the reoperative specimen. In two patients, there was microscopic but not macroscopic disease. Forty-four patients (48.9%) had identifiable macroscopic residual disease in the reoperative specimen. When comparing these 44 patients with visible (macroscopic) residual tumor to the remaining 46, no differences were seen in age, sex, stage, histologic type, time from excision to reoperation, or size of initial lesion. This previously unrecognized high incidence of gross residual disease must be considered when planning definitive therapy. Unplanned total excisions are inadequate to remove local disease and, despite multimodality therapy, may result in local failure. Reoperation should be a planned part of definitive management for patients with soft-tissue sarcoma of the extremity whenever the initial surgical procedure was done without a histologic diagnosis or was not planned to be a wide excision. If reoperation cannot be performed, radiotherapy doses to treat gross residual disease should be used.

Adolescent↗

PubMed1999

Reoperation for herniated thoracic discs.

OBJECT: In this review the authors address the surgical strategies required to resect residual herniated thoracic discs. METHODS: Data obtained in 15 patients who had undergone prior thoracic discectomy and who harbored residual or incompletely excised symptomatic thoracic discs were reviewed retrospectively. The surgical procedures that had failed to excise the herniated discs completely included 11 posterolateral approaches, one thoracotomy, and three thoracoscopy-guided surgical procedures. Of the lesions that were incompletely resected or residual, there were 13 central calcified, two soft. 12 extradural, and three intradural discs. Indications for reoperation were often multiple in each patient and included misidentification of the level of disc disease at the initial operation (five cases), abandoning the procedure because of intraoperative spinal cord injury (three cases), inadequate visualization of the pathological entity (eight cases), migration of a soft disc fragment within the spinal canal (one case), and intradural disc extension (three cases). The symptoms at the time of reoperation included myelopathy in 13 patients and radicular pain in two patients. The mean interval before reoperation was 150 days (range 1 day-4 years). The reoperation procedures included one thoracotomy and 14 video-assisted thoracoscopic procedures performed ipsilateral (11 cases) or contralateral (four cases) to the site of the initial surgery. The herniated disc material was excised completely in all 15 cases without causing new neurological deficits. Reoperation complications included atelectasis in three patients, intercostal neuralgia in two, a loosened screw that required removal in one, residual intradural disc herniation that required a second reoperation in one patient, and a cerebrospinal fluid leak in one patient. Of the 13 patients who experienced myelopathy prior to operation, 10 recovered neurological function and three stabilized. All patients with radicular pain improved. CONCLUSIONS: Calcified, large, broad-based, centrally located, or transdural thoracic disc herniations can be difficult to resect. These lesions require a ventral operative approach to visualize the dura adequately for a safe and complete resection.

Calcinosis↗

PubMed2005

The clinical course of recurrent exotropia after reoperation for exodeviation.

PURPOSE: To determine the clinical course of recurrent exotropia after a secondary operation for exotropia. METHODS: The surgical results in 58 patients who had undergone reoperation for recurrent exotropia (reoperation group) were retrospectively investigated and compared with those of 100 patients who had undergone primary strabismus surgery only (primary operation group) using survival analysis. RESULTS: In the reoperation group, recurrence occurred in 19 of the 58 patients (33%). Survival analysis revealed that the recurrence rates in the reoperation group were significantly lower than those in the primary operation group at the same follow-up period after the corresponding strabismus surgery (p=0.018). The distant esodeviation at the postoperative 1st week after reoperation was the only significant factor associated with the recurrence after reoperation (p=0.01). CONCLUSIONS: Exotropia did recur after a secondary operation, although the recurrence rate was lower than that after a primary operation only.

Child↗

PubMed1990

Reoperation: cardiac surgery.

The subject of cardiac reoperation in general has been infrequently discussed in the medical literature and has not yet appeared in the nursing literature. Yet reoperation presents a real challenge, accentuating some problems that are also associated with primary cases and posing some considerations that are unique to the reoperative situation. The objectives of this article are to discuss the reasons prompting reoperation for coronary revascularization, identify technical problems associated with reoperative coronary artery surgery, explore potential avenues for decreasing the need for reoperation, and discuss potential patient care problems in the immediate postoperative critical care setting.

Cardiac Surgical Procedures↗

PubMed1999

Determinants of hospital survival following reoperative single valve replacement.

OBJECTIVE: To determine the indicators of risk for hospital death, patients undergoing reoperative valve replacement were analyzed METHODS: Four hundred and eighteen consecutive patients undergoing reoperative valve replacement from 1977 to 1994 were reviewed using univariate and multivariate analysis. RESULTS: Overall hospital mortality was 11.2% with 9.4% mortality with aortic valve replacement and 14.2% with mitral valve replacement (P=0.52). Mortality was 9.7% for patients less than 70 years of age compared with 19.4% for older patients (P=0.03), and was 8.5% for those with anoxia times less than 90 mins versus 21.9% for those with longer anoxia times (P=0.001). For first reoperations, 9.5% of patients died, while for patients undergoing second or more reoperation, mortality was 23.2% (P=0.01). While mortality increased from 8.9% to 19.0% with the addition of a concomitant procedure (P=0.008), it was not affected if the additional procedure was a coronary bypass (P=0. 96). The indication for surgery influenced outcome. Mortality was zero for thromboembolism, 9% for structural failure, 23% for nonstructural failure and 22% for endocarditis (P=0.006). For New York Heart Association (NYHA) functional class I patients, mortality was 1.6% compared with 22.3% for those in NYHA class IV (P=0.006). By multivariate analysis, however, only the indication for surgery and the NYHA functional class influenced survival. CONCLUSIONS: Reoperative valve surgery can be performed with a survival (88.8%) that is similar to the initial procedure (91.2%). The indication for surgery and NYHA functional class alone influenced outcome; therefore, possible early reoperation is indicated before clinical deterioration occurs.

Aged↗

PubMed2001

Reoperation on the thymus. A critique.

Reoperation on the thymus, including even multiple re-resection, is a useful modality in carefully selected patients for recurrent thymoma or for incompletely removed thymus. In the case of MG, reoperation is used for completion of an otherwise incomplete thymectomy, usually by the transcervical method, although it also has been used after primary sternotomy. Interestingly enough, no instances of reoperation after primary VATS thymectomy have been reported yet. Indeed, VATS has been used successfully for reoperation after previous transcervical and trans-sternal thymectomies. In the case of thymoma, there have been an increasing number of reports of reoperation, including multiple procedures, in many cases. It is important to interpret the results of reoperation in the context of the biologic behavior of the thymus tumor. Thus far, no formal guidelines have been established for the follow-up of these patients. It is believed that all cases of thymectomy with or without thymoma and with or without MG should be followed for the lifetime of the patient with periodic examinations and imaging.

Adult↗

PubMed2001

Paravalvular leakage after mitral valve replacement: is left atrial enlargement an additional indication for reoperation?

BACKGROUND AND AIM OF THE STUDY: Prostheses used to treat heart valve disease improve patient survival, but have certain disadvantages. Paravalvular leakage (PVL) is a rare complication after mitral valve replacement (MVR), and can impair cardiac function and reduce the patient's functional capacity, depending on the degree of periprosthetic regurgitation. METHODS: Between 1985 and July 1999, 2,502 patients underwent MVR with or without concomitant cardiac procedures. Of these patients, 33 (18 males, 15 females; mean age 39.8+/-15.3 years; range: 12-62 years) had PVL of differing degree. The interval between MVR and observation of PVL was 30.5+/-31.5 months (range: 1-126 months), and the period after diagnosis was 22.6+/-31.5 months (range: 2-114 months). Fourteen patients (42.4%) underwent reoperation (RO group), and 19 (57.6%) were followed medically (ME group). Indications for reoperation were reduction of functional capacity, echocardiographically proven serious mitral regurgitation, and hemolysis. RESULTS: Reoperative mortality was 3.0% (1/33), and late mortality 3.1% (1/32) for all patients. Cumulative survival after PVL was 90.2+/-6.7% at both five and ten years. Annular calcification (33.0%) and infective endocarditis (18.2%) were important predictive factors for development of PVL. Only one patient required second re-do surgery. Univariate and forward stepwise logistic regression analyses showed that there was no predictor for the development of severe PVL requiring a second reoperation. No difference was observed between left ventricular dimensions before and after periprosthetic regurgitation. The only significant finding between groups was an increase in left atrial diameter in RO patients after the development of PVL (p <0.05). CONCLUSION: Among patients undergoing MVR there are no clinical features to distinguish who will develop severe PVL during follow up. If PVL reduces the patient's functional capacity or causes serious hemolysis, or if severe PVL is evaluated echocardiographically, then reoperation must be performed. Mild or moderate mitral regurgitation without impairment of functional capacity may be followed medically. In asymptomatic patients, enlargement (>5%) of the left atrial diameter following development of moderate PVL may be a valuable criterion for deciding when to reoperate.

Adolescent↗

PubMed2001

Reoperation for Freestyle stentless aortic valves.

Ten patients who initially underwent Freestyle stentless aortic valve implantation required reoperation. The goal of this study was to describe the reoperative techniques used and to review the outcomes of reoperation in patients with Freestyle stentless aortic valves. From September 1992 to April 2001, at the University of Michigan, a total of 552 Freestyle stentless aortic valves were implanted, and in 10 (1.8%) of these patients (7 men, 3 women) a reoperation was required. The mean age at the time of the initial implantation was 53.5 +/- 14.1 years. Implantation techniques included both modified inclusion root (7) and inclusion root (3). Reasons for reoperation included endocarditis (7), aortic aneurysm (1), valve dehiscence (1), and subvalvular outflow tract obstruction (1). Eight patients underwent homograft reimplantations and in 2 Freestyle reimplantations. In all cases, the previous aortotomy was re-entered, the pseudoendothelial layer over the distal suture line of the noncoronary sinus was incised and continued into the other 2 sinuses. Utilizing a ganglion knife, the Freestyle valve was freed from the native aortic tissue to the proximal suture line. The Dacron sewing ring was then separated using sharp dissection and the lower suture line excised. No calcification was noted in any case. The mean time interval between the first and second operative procedure was 13.4 +/- 21.5 months. There were no operative deaths and only one late death. Mean long-term follow-up was 43 +/- 29 months. Reoperation on a Freestyle stentless aortic valve, when necessary, can be accomplished without increased operative risk and with excellent survival.

Adult↗

PubMed2002

Cardiac valve reoperations: analysis of operative risk factors in 154 patients.

BACKGROUND AND AIMS OF THE STUDY: The study aim was to evaluate the operative risks of reoperation on heart valve prostheses. METHODS: Between January 1985 and December 2000, 154 patients (79 males, 75 females, mean age 61.2+/-9.5 years) underwent cardiac valve reoperation for which indications were prosthetic failure (n = 133; prosthetic mitro-aortic dysfunction occurred in 16 cases), native valve disease in patients with a previous prosthetic valve implantation (n = 12), and both situations concomitantly (n = 9). Total valve replacements numbered 161 (64 in the aortic position, 96 in the mitral position, and one in the tricuspid position). There were 18 valve repairs (eight in the mitral position, 10 in the aortic position). One patient underwent prosthesis thrombectomy (mechanical valve). RESULTS: Overall operative mortality was 8.4% (n = 13); emergency operation (p <0.002), advanced NYHA class (p <0.026), indication for reoperation (p <0.026), gender (p <0.016) and number of previous reoperations (p = 0.05) were independent determinants for reoperation. Non-significant determinants were age and position of replacement. CONCLUSION: Correct planning of reoperation timing reduces operative risks due to NYHA class (3.8% mortality rate for class II-III versus 21.7% for class IV), and to urgent-emergency procedures (35.7% mortality versus 6.5% for elective operations). The high operative risk of prosthesis thrombosis is a deterrent to implanting mechanical prostheses in patients with disorders of hemostasis.

Adult↗